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European Standards and North American Practice Parameters for Skin Prick Testing Panels in Allergic Rhinitis and Asthma

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European Standards and North American Practice Parameters for Skin Prick Testing Panels in Allergic Rhinitis and Asthma Romanian Journal of Rhinology, Vol. 5, No. 17, January-March 2015 DOI: 10.1515/rjr-2015-0002 LITERATURE REVIEW European standards and North American practice parameters for skin prick testing panels in allergic rhinitis and asthma Florin-Dan Popescu Department of Allergology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania ABSTRACT According to the Global Allergy and Asthma European Network (GA²LEN), a pan-European skin prick test panel for the diag- nosis of allergic rhinitis and asthma includes 18 aeroallergen extracts, supplemented if necessary for regional or for particular patient needs, while the Allergen Subcommittee and Immunotherapy Committee of the American Academy of Allergy, Asthma and Immunology (AAAAI) selected 36 major clinically relevant aeroallergens for North America. KEYWORDS: aeroallergen extracts, skin prick tests, allergic rhinitis and asthma INTRODUCTION PARAMETERS FOR SKIN PRICK TESTING PANELS Skin prick testing is an important reliable method to diagnose IgE-mediated allergic rhinitis, rhinocon- The aeroallergen extracts included in the Euro- junctivitis and asthma. This widely used in vivo assess- pean standards and North American practice param- ment, indicated, performed and interpreted by al- eters skin prick panels are of plant, fungal and ani- lergy practitioners, is minimally invasive, has immedi- mal origins, as described below1-8. ately available and reproducible results, and provides Aeroallergen extracts of animal origin included in evidence for aeroallergen sensitization. Skin prick these standards belong to Arthropoda phylum, Astig- tests are highly specific and sensitive for the diagnosis mata order (house dust mites from the Pyroglyphidae of respiratory allergies. The positive predictive value family), Blattodea order (Ectobiidea family from the to diagnose allergic rhinitis increases to 97-99% if al- Insecta class), and Carnivora order pet animals (Felidae lergy skin prick testing is utilized1,2. and Canidae families). According to the Global Allergy and Asthma Euro- Allergen extracts of fungal origin mentioned in pean Network (GA²LEN), a pan-European skin prick the European and North American recommenda- test panel for the diagnosis of allergic rhinitis and tions belong to moulds from the phylum Ascomycota asthma includes 18 aeroallergen extracts, and these (Dothideomycetes and Eurothiomycetes classes). allergens can be supplemented, if necessary, for re- Pollen from trees or shrubs from Fagales order gional or for particular patient needs2. The Allergen (Betulaceae and Fagaceae families), Malpighiales order Subcommittee and Immunotherapy Committee of (Salicaceae family), Lamiales order (Oleaceae family), the American Academy of Allergy, Asthma and Im- Proteales order (Platanaceae family), Sapindales order munology (AAAAI) previously compiled and selected (Aceraceae family), Rosales order (Moraceae and Ul- 36 key aeroallergens in North America3. maceae families), and Coniferales order (Cupressaceae family), grass pollen from Poales order, Poaceae Corresponding author: Florin-Dan Popescu, MD, PhD, Associate Professor, Head of Department of Allergology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania; Address: “Nicolae Malaxa” Clinical Hospital, 12 Sos. Vergului, Bucharest, Sector 2, Romania e-mail: [email protected] 20 Romanian Journal of Rhinology, Vol. 5, No. 17, January-March 2015 (gramineae) family (Pooideae, Chloridoideae and Pani- Aeroallergens of animal origin, such as those from coideae subfamilies), and pollen from weeds belong- house dust mites, domestic pets and insects, are im- ing to Asterales order (Asteraceae / Compositae family), portant indoor allergens involved in allergic rhinitis Rosales order (Urticaceae family), Lamiales order (Plan- and asthma as discussed below1-3,6-8,17,25-30. Spending taginaceae family), Caryophyllales order (Polygonaceae more time inside buildings (at work and at home) and Amaranthaceae / Chenopodiaceae families) are in- creates conditions for more exposure to multiple in- cluded in these panels. door aeroallergens. House dust includes various or- Weather and climate change the impact of aeroal- ganic and inorganic matter, including dust mites, lergens in Europe and North America6,9-12, particu- animal dander, cockroach debris and other insect larly pollens and moulds. Climatological regimes parts, natural and synthetic fibers, but also moulds, (warm or cold anomalies, dryer and wetter periods), pollen grains and inorganic debris. House dust mites along with meteorological factors (temperature, are the most common and important indoor aller- wind speed, humidity, rain, thunderstorms), are in- gens. volved. It is known that human activities increase at- House dust mites belong to the phylum of Arthrop- mospheric greenhouse gases, such as carbon dioxide. oda (class Arachnida, subclass Acari), Astigmata order, Over the last decades, raised temperatures and at- Pyroglyphidae family, and the most important species mospheric carbon dioxide concentration have im- are Dermatophagoides pteronyssinus and Dermatophagoi- pacted plant and pollen distribution, and induced des farinae, and this is the reason why allergen extracts changes in the quantitative production and disper- of these domestic mites are included in European sion of pollen, pollen season periods and allergen standards and North American practice parameters content of pollen grains, which may be region- and skin prick panels. Pyroglyphid mites are highly cross- species-specific. During the last decades, several reactive, but they seem to have a limited cross-reactiv- changes described below were observed6,13-24. Some ity with storage mites found in farms, and Blomia anemophilous plants pollinate earlier, the duration tropicalis, significant mite species in tropical or sub- of the pollen season is extended in some species, and tropical areas. These non-pyroglyphid mite extracts there are more days with greater airborne pollen are used only in selected cases, and are not included grain concentrations. Production of allergenic pollen in pan-European and North American screening of some weeds is increased with high ambient carbon panels. dioxide levels. Moreover, higher daily temperatures The most important urban indoor inhalant insect may increase pollen allergenicity. Climate changes allergens in Europe and North America derive from may also lead regionally to the extinction of some domestic cockroach species, especially Blattella ger- plant species and to the proliferation of non-native manica (German cockroach), this one being included alien species with allergenic pollens. in North American and European standard panels. According to standardized skin prick testing per- Aeroallergens of small mammal pets from the Car- formed at excellence centres in European countries, nivora order (epithelia/dander) belong to the Felidae the Global Allergy and Asthma European Network family: Felis catus syn. Felis domesticus (domestic cat) (GA²LEN) in association with the European Acad- and Canidae family: Canis lupus familiaris syn. Canis emy of Allergy and Clinical Immunology (EAACI) familiaris (dog). Both are included in European and suggested a panel of aeroallergens for skin prick test- North American practice parameters skin prick pan- ing in all European patients. As mentioned before, els. In selected cases, other mammalian allergen ex- allergen extracts can be supplemented if necessary tracts may be used (horse, domestic guinea pig, ham- for regional or for particular patient needs2. The ster, rabbit). American Academy of Allergy, Asthma and Immunol- Aeroallergens of fungal origin involved in allergic ogy (AAAAI) previously selected a double number of sensitization in rhinitis and asthma1-3,6-8,17,31-34 are key aeroallergens in North America compared with moulds belonging to the phylum Ascomycota, class actual European standard. For an individual patient, Dothideomycetes, Pleosporaceae family: Alternaria alternata the choice of allergen extracts for skin prick testing syn. Alternaria tenuis, Davidielaceae family: Cladosporium should be guided primarily by the patient’s detailed herbarum, Cladosporium cladosporioides (both types history and physical examination, by the sciences of being predominantly outdoor moulds, with dry aerobiology, botany, mycology, arthropod biology, spores), and class Eurothiomycetes, Trichocomaceae fam- and the contact with companion animals. In North ily: Aspergillus fumigatus (predominantly indoor America, it is not possible to elaborate a universal list mould). Alternaria alternata, Cladosporium spp and As- of appropriate aeroallergens for skin prick testing in pergillus fumigatus are included in North American all patients. The selection of allergen extracts for in and European standard panels. The North American vivo testing reflects the physician’s knowledge, train- practice parameters skin prick panel includes in ad- ing and experience3. dition fungi belonging to class Eurothiomycetes, Tricho- Popescu European standards and North American practice parameters for skin prick testing panels in allergic rhinitis and asthma 21 comaceae family: Penicillium chrysogenum syn. Penicil- spread in the temperate zone; their pollen represents lium notatum, Penicillium expansum, and dematiaceous a substantial proportion of grass pollen grains to fungi from class Dothideomycetes: Bipolaris/Curvularia/ which European and American rhinitis patients are Drechslera spicifera syn. Helminthosporium spiciferum, sensitized,
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